CurrentModa HealthPolicy N/A

Moda Health Medicare Supplement Plan G coverage summary

This document governs the benefits, definitions, and administrative provisions of Moda Health Medicare Supplement Plan G for subscribers; it outlines eligibility, member resources, benefit coverage (core and additional), and policy disclosures for covered individuals in the referenced plan materials.

Policy Summary

PayerModa Health

PolicyMedicare Supplement Plan G

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must file claims with Medicare first and notify Moda Health of Medicare's payment before secondary benefits are paid.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365maximum additional inpatient hospital days covered in lifetime

80%coverage level for emergency care in foreign country

$250foreign emergency deductible (annual)

$50,000foreign emergency lifetime maximum

15 monthsclaim submission period

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30 daysstandard claim processing time

Coverage rules, benefits, and member eligibility

Coverage Criteria and Benefits

Plan G provides Core Benefits (A–F) and Additional Benefits (a–d) when Medicare eligibility and policy conditions are met.

ALL of the following

Part A hospital coinsurance (days 61–90): payable for hospital stays covered under Medicare Part A during a benefit period.
Part A lifetime hospital reserve days coinsurance: payable for each of Medicare's 60 non-renewable lifetime reserve days.
Additional inpatient hospital care after Medicare exhausted: 100% of Medicare Part A eligible hospital expenses up to a 365‑day lifetime maximum; paid at the Medicare payment rate (PPS or other applicable standard).
First 3 pints of blood (Part A and Part B) per calendar year and 20% coinsurance for additional Part B pints after the Part B deductible is met.
Part B coinsurance/copayment: coinsurance or copayment amount for Medicare Part B eligible expenses after the Part B deductible is met.
Part A hospice and respite care coinsurance: payable as the Medicare eligible coinsurance amounts for hospice and respite care.

ALL of the following

Medicare Part A inpatient hospital deductible: Plan covers the Part A deductible.
Medicare Part B excess charges: Plan covers 100% of Part B excess charges.
Skilled nursing facility coinsurance: covers the coinsurance amount for days 21–100 per benefit period for SNF care covered by Medicare Part A.
Emergency care in foreign country: medically necessary emergency care covered at 80% after a $250 calendar year deductible, limited to a $50,000 lifetime maximum; benefit payable only when care begins within first 60 days of trip and would have been covered by Medicare if provided in the U.S.

ALL of the following

Right to examine (free look): subscriber may return the policy within 30 days for a refund; policy is void from the effective date upon return.
Premium and benefit change notices: required premium may change once in a 12‑month period; prior notice requirements apply to benefit changes before annual renewal.
Provider payment rule: service providers must accept the Plan's payment as payment in full and may not bill the subscriber for any balance for covered services.
Benefit period definition: benefit period begins on the day of hospitalization and ends after 60 consecutive days out of hospital or skilled nursing; a new benefit period restarts if hospitalized after 60 days.

Eligibility: any person age 65 or older (and Alaska residents within first 6 months of enrolling in Medicare Part B) may enroll; a subscriber must be enrolled in Medicare Part A and Part B to remain eligible under the Plan.

Core coverage criteria and exclusions

Eligibility and benefit payment conditions and key exclusions

Hospital stays: benefits are payable only if the hospital stay begins on or after the policy effective date and is covered under Medicare Part A during a benefit period; lifetime reserve and additional 365‑day conditions apply.

Medical (Part B) services: payable when Medicare Part B has paid its portion as required and services occur on or after the policy effective date; inpatient medical care must be part of a stay that began on or after the effective date.

Skilled nursing facility stays: payable if covered under Medicare Part A during a benefit period, begins within 30 days after a qualifying 3+ day inpatient hospital stay, repeated confinements are for the same condition, and both stays start while covered under the Plan.

Foreign emergency care: payable only for emergency care during a trip outside the U.S. that would have been covered by Medicare if provided in the U.S., is not eligible for Medicare payment, begins within the first 60 days of the trip, is subject to a $250 calendar year deductible, and is limited to a $50,000 lifetime maximum; benefits are payable only to the subscriber in U.S. currency.

Medicare interactions, non-duplication, and motor vehicle accidents

Rules governing interactions with Medicare, duplicate benefits, and motor vehicle-related claims:

When Medicare is secondary payer: if Medicare becomes secondary because of other coverage, benefits under this Plan are paid as if Medicare's normal Part A and Part B benefits had not been reduced.

Non‑duplication of benefits within Plan: services are eligible for only one type of benefit under the Plan (e.g., skilled nursing care is reimbursed only under that benefit).

Motor vehicle accidents: expenses payable under a motor vehicle insurance policy are not covered by the Plan. Moda Health may advance benefits pending motor vehicle insurer payment but retains subrogation and recovery rights.

Subrogation and right of recovery

Third-party recovery, subrogation, and subscriber obligations:

Subrogation: upon payment by the Plan, Moda Health is subrogated to the subscriber's rights of recovery and may pursue recovery in its own name or in the subscriber's name.

Right of recovery: the subscriber holds recovery rights in trust for Moda Health for amounts the Plan paid; Moda Health is entitled to reimbursement from settlements or judgments regardless of characterization, and may require a signed reimbursement agreement before paying benefits.

Subscriber cooperation obligations: the subscriber and their representatives must notify Moda Health in advance of any third‑party claim or lawsuit, cooperate in protecting Moda Health's rights, sign required documents (including reimbursement agreements), provide requested information (medical records, settlement documents, pleadings), and take actions requested to assist recovery; failure to comply may result in suspension, non‑advancement, or recovery of benefits advanced.

Information release: Moda Health may release or obtain information from other insurers or parties without the subscriber's written authorization to carry out reimbursement and recovery rights; these provisions apply even if the event occurred before coverage started when advance payment was made.

Membership, grace/reinstatement, termination, Medicaid, and age misstatement

Membership and premium-related provisions:

Termination for loss of Medicare: the Plan terminates if a subscriber ceases to be insured under either Medicare Part A or Part B.

Effect of change of plan: if a subscriber changed from another Moda Health supplement plan effective the same date, benefits paid under the prior plan are not payable under this Plan for the same stay or care.

Grace period: subscribers have a 31‑day grace period after the premium due date; coverage remains in force until the end of the grace period but the premium must be paid for coverage during that time. The grace period does not apply if the Plan is replaced by another health plan effective that date.

Reinstatement: reinstatement requires an application and conditional receipt; policy reinstates upon approval or on the 45th day after conditional receipt unless disapproved; reinstated coverage initially covers accidental injury claims immediately and sickness claims after 10 days; premiums accepted for reinstatement apply to periods not previously paid but not more than 60 days prior to reinstatement.

Medicaid Suspension/Reinstatement

Medicaid-related suspension and reinstatement rules

Medicaid entitlement suspension: if a subscriber becomes entitled to Medicaid, benefits and premiums under the Plan may be suspended for up to 24 months if suspension is requested within 90 days of becoming eligible.

Reinstatement request window: reinstatement must be requested within 90 days of losing Medicaid entitlement; reinstatement may be effective as of the date Medicaid entitlement is lost if premiums due for that period are paid.

Plan selection on reinstatement: if reinstated, coverage will be under the same plan if available, or under a plan providing substantially equivalent coverage.

Recovery of Improper Payments

Recovery of payments not required under Plan terms

Recovery time limit: Moda Health may initiate recovery of an improperly made payment within 365 days of the original payment date.

Notification and challenge: Moda Health will provide 30 calendar days written notice prior to recovering a payment; the notified party has the right to challenge the recovery.

Potential recovery targets: recoveries may be sought from any person to or for whom payments were made, any insurance companies, or any other organization or person.

Misstated Age Adjustment

Adjustment for misstated age

If the subscriber's age was misstated at enrollment, all amounts payable under the policy will be adjusted to the amounts that the premium paid would have purchased at the correct age.

Coding, billing, and claim timelines

Billing/coding guidancemixed

No explicit billing/coding lists provided in this section.

Foreign Emergency Lifetime Maximum

Foreign emergency lifetime maximum$50,000

Foreign Emergency Deductible

Foreign emergency deductible per calendar year$250

Claim Processing Deadlines

Standard claim processing time for complete claims30 days from receipt to pay or deny and issue EOB

Time allowed to submit requested additional information45 days from notice to submit required information

What providers and members must do

Note

Member & Provider Contact

For help, call Moda Health Medical Customer Service toll-free at 844-235-8012. Telecommunications Relay Service 711.

Billing Rule

Claims Filing Requirement

Electronic claims filing is available. Before the Plan can pay any benefits, the provider must file a claim with Medicare first. Moda Health must receive notification from the Medicare carrier of its payment before paying secondary benefits. If a bill is electronically filed, it may indicate the claim has been forwarded to your secondary Medicare payor. Mail claims (with the Medicare Summary Notice) to: Moda Health PO Box 40384 Portland, OR 97240. Except for absence of legal capacity, claims must be submitted no later than 15 months from the date the expense was incurred. Only charges determined by Medicare to be Medicare-eligible expenses will be covered under the Plan.

Key definitions used in this policy

Approved Amount

Approved Amount (Medicare Part B)Amount Medicare determines to be reasonable for a Medicare Part B service; may be less than the charge

Assignment

AssignmentArrangement where a provider accepts the Medicare-approved amount as full payment; Medicare usually pays 80% of the approved amount after the Part B deductible is met

Medical Emergency

Medical EmergencySudden and unexpected onset of symptoms, illness, injury or condition that would carry substantial risk of serious medical complication or permanent damage if care is withheld

Foreign emergency care conditionEmergency care while on a trip outside the U.S. that begins within the first 60 days of the trip and would have been covered by Medicare if provided in the U.S.

Policy Summary

PayerModa Health

PolicyMedicare Supplement Plan G

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must file claims with Medicare first and notify Moda Health of Medicare's payment before secondary benefits are paid.

SourceLink

On This Page

No benefits for the Medicare Part B deductible: the Plan does not provide benefits for the Part B deductible.

Duplicate benefits: the Plan will not duplicate any amounts payable under Medicare; only charges Medicare determines to be Medicare‑eligible expenses are covered.

Government‑owned hospitals: no coverage for stays, services, supplies or facilities provided by government‑owned or -operated institutions unless payment is required by law.

Outpatient prescription drugs: no benefits for outpatient prescription drugs except outpatient drugs covered by Medicare Part A for hospice care.

Services not covered by Medicare: no benefits are provided for charges that are not covered expenses under the subscriber's Medicare plan unless specifically stated.

Workers' compensation: the Plan will not cover injury or sickness for which the subscriber is entitled to benefits under workers' compensation or similar law.

Enrollment eligibility: enrollment available to persons at least age 65 and Alaska residents within first 6 months of enrolling in Medicare Part B; must be enrolled in Medicare Part A and B to remain eligible.

Benefits after coverage stops: if policy terminates while subscriber is hospitalized, the Plan will continue to pay toward that hospitalization until discharge or benefits exhausted.

Claim filing requirement: providers must file claims with Medicare first; only Medicare‑eligible charges will be covered by the Plan.

Foreign claims documentation: for out‑of‑country claims, subscriber must provide identifying information, statement of circumstances, medical records (translated when possible), itemized bill, and proof of payment if no assignment of benefits was made.

Payment rules: Plan payments are made to whoever received Medicare benefits; foreign emergency care benefits payable to subscriber unless assignment requested; providers may collect at discharge and the member will be reimbursed if later covered.

Explanation of Benefits and timelines: Moda Health issues an EOB after claim action; complete claims are paid or denied within 30 days; if additional information is required, 45 days are allowed to submit; once info received, processed within 15 days or within 30 days of original receipt; late processing may accrue interest (see policy).

Future medical expenses: if future medical expenses are expected, the subscriber must seek recovery for future expenses in third‑party claims so that Moda Health's interests are protected.

Voluntary termination: subscriber must give 30 days written notice to Moda Health to voluntarily terminate coverage.

Medicaid suspension: benefits and premiums may be suspended during Medicaid entitlement for up to 24 months if suspension is requested within 90 days of becoming eligible; reinstatement may be requested within 90 days of losing Medicaid entitlement and may be made retroactive if premiums due for that period are paid.

Misstated age: if the subscriber's age was misstated at enrollment, amounts payable under the policy will be those the premium paid would have purchased at the correct age.

Adjudication time after receipt of additional information15 days after receipt (or 30 days from original receipt) to complete processing

Billing Rule

Foreign Provider Payment/Assignment

For foreign travel emergency care, benefits will be paid to whoever received the Medicare benefits. However, foreign travel emergency care benefits will be payable directly to the subscriber unless the member requests assignment of benefits to the provider. If a foreign provider requires payment at the time of discharge or treatment, the member must pay to receive services; Moda Health will reimburse the member directly for any charges later determined to be covered by the Plan. Providers must follow the claim filing process described in the Claims Filing Requirement section.

Note

Explanation of Benefits

Soon after receiving a claim, Moda Health will report its action by providing the subscriber an Explanation of Benefits (EOB). Subscribers are encouraged to enroll in Member Dashboard to access EOBs electronically. Moda Health may pay, deny, or accumulate claims toward the deductible; if all or part of a claim is denied, the reason will be stated in the EOB. If a subscriber does not receive an EOB or an email indicating availability within a few weeks of the date of service, Moda Health may not have received the claim. To be eligible for reimbursement, claims must be received within the claim submission period in the Claims Filing Requirement section.

Note

Claims additional information workflow and timelines

If no additional information is needed, Moda Health will pay or deny the claim and send an EOB within 30 days after receiving the claim. If additional information is required, Moda Health will send a notice describing the information needed and who is responsible for providing it; that party will have 45 days to submit the information. Once the additional information is received, processing will be completed within 15 days of receipt of the information or within 30 days of the original receipt of the claim. If a claim is not completed timely, interest at 15% annually will accrue until processing is complete. Submission of additional information is still subject to the claim submission period described in the Claims Filing Requirement section.

Note

Claim inquiries

Customer Service can answer questions about how to file a claim, the status of a pending claim, or any action taken on a claim. See the Member & Provider Contact section for phone numbers.

Billing Rule

Medicaid Suspension and Reinstatement

Benefits and premiums under the Plan will be suspended during a subscriber's entitlement to Medicaid for up to 24 months if suspension is requested within 90 days of becoming eligible for Medicaid. If the subscriber is no longer entitled to Medicaid, coverage will be reinstated if the subscriber requests reinstatement within 90 days of losing Medicaid entitlement. Coverage may be reinstated effective the date Medicaid entitlement ended if premiums due for that period are paid. Reinstated coverage will be under the same plan (if available) or a plan providing substantially equivalent coverage.

Medicare Eligible Expenses

Medicare Eligible ExpensesExpenses of the kind covered by Medicare to the extent recognized as reasonable and medically necessary by Medicare

Subscriber

SubscriberThe person in whose name the policy is issued following acceptance by Moda Health of that person’s health statement application

Emergency Care (Foreign)

Emergency care (foreign) — definitionCare needed immediately because of an injury or illness of sudden or unexpected onset while on a trip outside the United States

Foreign emergency benefit conditionsMust begin within first 60 days of trip, not be eligible under Medicare, be the type Medicare would cover in U.S., $250 calendar year deductible met, and lifetime maximum $50,000

Activities of Daily Living

Activities of daily living (ADLs)Include bathing, dressing, personal hygiene, transferring, eating, ambulating, assistance with self-administered drugs, and changing bandages or other dressings

Benefits

BenefitsAny amount paid by Moda Health, or submitted to Moda Health for payment to or on behalf of the subscriber; provider bills are considered requests for payment by the subscriber

Provider-submitted billsBills, statements or invoices submitted by a provider to Moda Health are treated as requests for payment of benefits by the subscriber

Recovery Funds

Recovery FundsAny amount recovered from a third party

Third Party

Third PartyAny person or entity responsible for the medical condition or its aggravation, including liability insurers and workers' compensation

Third Party Claim

Third Party ClaimAny claim, lawsuit, settlement, award, verdict, judgment, arbitration decision or other action against a third party by or on behalf of a subscriber

Misstatement of Age

Misstatement of Age — effectIf subscriber’s age was misstated at enrollment, amounts payable will be those that the premium paid would have purchased at the correct age

Entire Policy / Amendments

Entire Policy / AmendmentsThe application plus this document and any declaration pages, addendums, endorsements or amendments constitute the entire policy; no change is valid until approved by an executive officer and endorsed

Confidentiality of Member Information

Confidentiality of Member InformationProtected health information includes enrollment, claims, medical and dental information; used internally for claims payment, referrals, authorizations, case management and quality programs; Moda Health does not sell this information